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Management of Radiation Patients

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Emergency Department:
Management of Radiation Exposed/Contaminated Patients
CAUTION
This presentation, "Emergency Department: Management of Radiation
Exposed/Contaminated Patients,” was prepared as a public service by the
Health Physics Society for hospital staff training.
The presentation includes talking points on the Notes pages, which can be
viewed if you go to the File Menu and "Save As" a PowerPoint file to your
computer.
The talking points are provided with each slide to assist the presenter in
answering questions. It is not expected that all the information in the talking
points will be presented during the training.
The presentation can be edited to fit the needs of the user. The authors
request that that appropriate attribution be given for this material and
would like to know who is presenting it and to what groups. That
information and comments may be sent to Jerrold T. Bushberg, PhD, UC
Davis Health System, at jtbushberg@ucdavis.edu.
Protecting Staff from Contamination
• Follow universal precautions.
• Survey hands and clothing with a
radiation meter.
• Replace contaminated gloves or
clothing.
• Keep the work area free of
contamination.
Key Points
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Contamination is easy to detect and most of it can be
removed.
It is very unlikely that medical staff will receive large
radiation doses from treating contaminated patients.
Reducing Radiation Exposure
Time
Minimize time spent near radiation sources.
To Limit Caregiver Dose to 5 rem
Distance
Maintain maximal
practical distance from
radiation source.
Distance
Rate
Stay time
1 ft
12.5 R/hr
24 min
2 ft
3.1 R/hr
1.6 hr
5 ft
0.5 R/hr
10 hr
8 ft
0.2 R/hr
25 hr
Shielding
Place radioactive
sources in a lead
container.
Detecting and Measuring Radiation
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Instruments
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Locate contamination - GM Survey Meter
(Geiger counter)
Measure exposure rate - Ion Chamber
Personal Dosimeters - Measure doses
to staff
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Radiation Badge - Film/TLD
Self-reading dosimeter
(analog and digital)
Patient Management - Priorities
Triage
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Medical triage is the highest priority.
Radiation exposure and contamination
are secondary considerations.
Degree of decontamination is dictated
by number of and capacity to treat
other injured patients.
Patient Management - Triage
Triage based on:
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Injuries
Signs and symptoms - nausea,
vomiting, fatigue, diarrhea
History - Where were you when
the incident occurred, i.e. how far
from the actual event site?
Contamination survey
Contamination Surveys
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Survey with GM survey
meters.
Those familiar with the use
of radiation detection
instruments should operate
them.
Goal is <5 times
background.
Prepare protocol for survey
and documentation.
photo credits: REAC/TS
• Hold probe ~1/2 inch from surface.
• Move at a rate of 1 to 2 inches per
second.
• Follow logical pattern.
• Document readings in counts per
minute (cpm) .
Directions
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Clear directions (in
appropriate languages)
are necessary to help
individuals understand
what is expected of
them.
Surveying After Each Decontamination
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Provisions must be
provided for repeat
surveying of individuals
after each decontamination
procedure to determine
success of efforts and
when individuals can be
routed out of the
decontamination center.
photo credits: REAC/TS
Mass Decontamination Facilities
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Where possible, the
decontamination of many
contaminated individuals should be
carried out in existing shower
facilities (e.g., at a fire house,
school locker room, or public
campground).
When such facilities are not
immediately available, field
decontamination capabilities
may have to be implemented.
Mass Decontamination
Mass Decontamination
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Runoff
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Responders should closely monitor the direction of runoff to
prevent cross contamination between lanes and between zones. If
possible, the decontamination area should contain a storm water
drain or be on a slope that allows control of water runoff.
EPA and Runoff
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The Environmental Protection Agency has stated that it will not
hold responders liable for runoff in a chemical or biological incident
caused by a terrorist event. (EPA letter dated 17 September 2000)
Protection of human life and health is primary goal.
Second-Stage Decontamination
Ambulatory Patients
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When surveying shows
that preliminary
decontamination of
individuals has not been
complete, they should
be sent to a secondstage decontamination
facility (e.g., specialized
decontamination tent).
Second-Stage Decontamination
Nonambulatory Patients
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Some specialized
decontamination tents
permit capabilities for
decontamination of
nonambulatory
patients as well as
those who can walk.
Clothing for Decontaminated Individuals
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Supplies of clean
clothing (sheets,
blankets, scrub suits,
etc.) should be available
for individuals exiting
decontamination
stations.
Provide plastic bags for
personal items, wallets,
jewelry.
Gowning Capabilities
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Patients exiting
second-stage
decontamination
facilities need to be
provided with clean
clothes (hospital
gowns, coveralls,
sheets or blankets).
Resurveying
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Individuals exiting the secondstage decontamination facility
should be surveyed again to
determine the effectiveness of
decontamination. Individuals
found to still be contaminated can
be rerouted through the secondstage decontamination effort.
Patient Management - Decontamination
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Carefully remove and bag patient’s clothing and
personal belongings (typically removes 95 percent of
contamination).
Survey patient and, if practical, collect samples.
Handle foreign objects with care until proven
nonradioactive with survey meter.
Decontamination priorities:
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Decontaminate wounds first, then intact skin.
Start with highest levels of contamination.
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Change outer gloves frequently to minimize spread of
contamination.
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Protect uncontaminated wounds with waterproof
dressings.
Patient Management - Decontamination
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Contaminated wounds:
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Irrigate and gently scrub with surgical sponge.
Extend wound debridement for removal of contamination only
in extreme cases and upon expert advice.
Avoid overly aggressive decontamination.
Change dressings frequently.
Decontaminate intact skin and hair by washing with soap &
water.
Remove stubborn contamination on hair by
cutting with scissors or electric clippers.
Promote sweating.
Use survey meter to monitor progress of
decontamination.
Patient Management - Decontamination
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Cease decontamination of skin and wounds:
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Contaminated thermal burns
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When the area is less than twice background, or
When there is no significant reduction between decon efforts,
and
Before intact skin becomes abraded.
Gently rinse. Washing may increase severity of injury.
Additional contamination will be removed when dressings are
changed.
Do not delay surgery or other necessary medical
procedures or exams . . . residual contamination can be
controlled.
Treatment of Internal Contamination
 Radionuclide-specific
 Most effective when administered early
 May need to act on preliminary information
 NCRP Report No. 65, Management of Persons
Accidentally Contaminated with Radionuclides
Radionuclide
Cesium-137
Iodine-125/131
Strontium-90
Americium-241/
Plutonium-239/
Cobalt-60
Treatment
Prussian blue
Potassium iodide
Aluminum phosphate
Ca- and Zn-DTPA
Route
Oral
Oral
Oral
IV infusion,
nebulizer
Treatment of Large External Exposures

Estimating the severity of radiation injury is difficult.
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Signs and symptoms (N,V,D,F): Rapid onset and greater severity indicate
higher doses. Can be psychosomatic.
CBC with absolute lymphocyte count
Chromosomal analysis of lymphocytes (requires special lab)
Treat symptomatically. Prevention and management of
infection is the primary objective.
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Hematopoietic growth factors, e.g., GM-CSF, G-CSF (24-48 hours)
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Irradiated blood products
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Antibiotics/reverse isolation
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Electrolytes
Seek the guidance of experts.
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Radiation Emergency Assistance Center/Training Site (REAC/TS)
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Medical Radiobiology Advisory Team (MRAT)
Patient Management - Patient Transfer
Transport injured, contaminated
patient into or out of the
emergency department:
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Cover clean gurney with two sheets.
Lift patient onto clean gurney.
Wrap sheets over patient.
Roll gurney into emergency
department or out of treatment room.
Facility Recovery
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Remove waste from the emergency department and triage
area.
Survey facility for contamination.
Decontaminate as necessary:
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Normal cleaning routines (mop, strip waxed floors) typically
very effective.
Periodically reassess contamination levels.
Replace furniture, floor tiles, etc., that cannot be adequately
decontaminated.
Decontamination goal: Less than twice normal background
. . . higher levels may be acceptable.
Special Considerations
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High radiation dose and trauma interact synergistically to
increase mortality.
For patients who received doses >100 rad:
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Close wounds, attend to any infection, look out for infections
Wound care, burn care, and surgery should be done in the first
48 hours or delayed for 2 to 3 months
Emergency
Surgery
Hematopoietic Recovery
24-48 Hours
~3 Months
No Surgery
Surgery
Permitted
After adequate
hematopoietic recovery
Other Considerations
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Victims may include the terrorist(s) (if this is a dirty bomb
situation).
In most cases, following universal precautions is all that is
necessary to protect the staff.
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Risk to caregivers, who would likely receive low doses, is very
small.
Hospital staff doses at Chernobyl <1 rem.
10 rem increases the risk of fatal cancer by ~1 percent.
25 rem increases the risk of severe hereditary effects by ~0.1
percent.
Preplan who will be given radiation dosimeters
Other Considerations
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Larger hospitals or large metropolitan areas should
consider stocking decorporation agents.
Dose rates to first responders 20 cm from patient with
uniform surface contamination:
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Cesium-137, 100 µCi/cm2 – 1 rem/hr
Cobalt-60, 100 µCi/cm2 – 3.9 rem/hr
Dose rates to surgeon standing 20 cm from patient
with radioactive fragment (0.2 mm long, 0.2 mm
radius, embedded 20 cm deep)
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Cobalt-60, 1 Ci – 2.5 rem/hr
Psychological Casualties
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Terrorist acts involving toxic agents (especially
radiation) are perceived as very threatening.
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Mass-casualty incidents caused by nuclear
terrorism will create large numbers of worried
people who may not be injured or contaminated.
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Establish a center to provide psychological
support to such people.
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Set up a center in the hospital to provide
psychological support for staff.
Psychological Casualties
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Affected by fear of radiation and misunderstanding
of consequences.
Long-term psychological effects could arise hours
or days after an incident.
Counsel on acute and potential long-term physical
and psychological effects.
Psychological effects include:
Anxiety disorders
Depression
Traumatic neurosis
Post traumatic stress disorder
Insomnia
Acute stress disorder
Psychological Casualties
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Provide psychological counseling to staff, victims,
and their families.
High-risk groups include emergency workers,
children, mothers with small children, cleanup
workers.
Provide exposed patients with a “sense of control
of their health.”
Resources:
http://www.madison.va.gov/PTSD
http://www.afrri.usuhs.mil/outreach/pdf/2edmmrchandbook.pdf
Contaminated Corpses
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Disaster Mortuary Operational Response Teams
(DMORT)
Restrict autopsies of highly radioactive corpses.
No embalming or cremation.
Health physics assistance for autopsies:
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Use contamination control.
Wear protective clothing.
Key Points
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Medical stabilization is the highest priority.
Train/drill to ensure competence and confidence.
Preplan to ensure adequate supplies and survey
instruments are available.
Universal precautions and decontaminating
patients minimize exposure and contamination
risk for staff.
Early symptoms and their intensity are an
indication of the severity of the radiation injury.
The first 24 hours are the worst; then you will
likely have many additional resources.
Acknowledgments
Prepared by the Medical Response Subcommittee of the National
Health Physics Society Homeland Security Committee.
Jerrold T. Bushberg, PhD, Chair
Kenneth L. Miller, MS
Marcia Hartman, MS
Robert Derlet, MD
Victoria Ritter, RN, MBA
Edwin M. Leidholdt, Jr., PhD
Consultants
Fred A. Mettler, Jr., MD
Niel Wald, MD
William E. Dickerson, MD
Appreciation to Linda Kroger, MS, who assisted in this effort.
пѓЈ Health Physics Society
Disclaimer: The information contained herein was current as of 13 Aug 2008 and is
intended for educational purposes only. The authors and the Health Physics
Society (HPS) do not assume any responsibility for the accuracy of the information
presented herein. The authors and the HPS are not liable for any legal claims or
damages that arise from acts or omissions that occur based on its use.
The Health Physics Society is a nonprofit scientific professional organization
whose mission is to promote the practice of radiation safety. Since its formation in
1956, the Society has grown to approximately 6,000 scientists, physicians,
engineers, lawyers, and other professionals representing academia, industry,
government, national laboratories, the Department of Defense, and other
organizations. Society activities include encouraging research in radiation science,
developing standards, and disseminating radiation safety information. Society
members are involved in understanding, evaluating, and controlling the potential
risks from radiation relative to the benefits. Official position statements are
prepared and adopted in accordance with standard policies and procedures of the
Society. The Society may be contacted at 1313 Dolley Madison Blvd., Suite 402,
McLean, VA 22101; phone: 703-790-1745; fax: 703-790-2672; email:
HPS@BurkInc.com.
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